This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This policy also describes how THE BRIDGE may use other information about you. Please review it carefully.

Who We Are: This Notice describes the privacy practices of THE BRIDGE, their employees (including counselors, nurses, and treatment aides), and other individuals that work at THE BRIDGE. (THE BRIDGE refers to the THE BRIDGE's residential substance abuse treatment centers, intensive outpatient centers, counselor offices, and other facilities.)

Our Privacy Obligations: Certain laws require THE BRIDGE to maintain the privacy of medical
and health information about you ("Protected Health Information") and to provide you with this
Notice of our legal duties and privacy practices with respect to Protected Health Information.
When we use or disclose Protected Health Information, we are required to abide by the terms
of this Notice (or other notice in effect at the time of the use or disclosure).

Uses and Disclosures with Your Consent or Your Authorization

A.Use and Disclosure With Your Consent. As a condition of treatment, except in an emergency or other special circumstances, we will ask you to read and sign a written consent ("Your Consent") to our use and disclosure of Protected Health Information for purposes of treatment provided to you, obtaining payment for services provided to you, and for our health care operations (e.g., internal administration, quality improvement, and customer service), as detailed below:

§Treatment. We use and disclose Protected Health Information to provide treatment and
other services to you; for example, to diagnose and treat your injury or illness. In addition,
we may contact you to provide appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be of interest to you.

§Payment. We may use and disclose Protected Health Information to obtain payment for
services that we provide to you at a BRIDGE facility. For example, we may use or disclose
Protected Health Information to claim and obtain payment from your health insurer, HMO,
or other company that arranges or pays the cost of some or all of your health care ("Your
Payer"), and to verify that Your Payer will pay for health care.

§Health Care Operations. At THE BRIDGE, we use and disclose Protected Health
Information for our health care operations, which include internal administration and
planning and various activities that improve the quality and cost effectiveness of the care
that we deliver to you.

B.Use or Disclosure with Your Authorization. As described above, Your Consent only permits us to use Protected Health Information for purposes of treatment, payment, and our health care operations. We may use or disclose Protected Health Information for any reason other than treatment, payment, and health care operations only when (1) you give us your authorization on our authorization form ("Your Authorization") or (2) there is an exception described in Section IV below.

Uses and Disclosures Without Your Consent or Your Authorization

A.Use or Disclosure For Treatment, Payment, and Health Care Operations Without Your Consent or Your Authorization. At THE BRIDGE, we may use or disclose Protected Health Information for purposes of treatment, obtaining payment, and our health care operations without Your Consent or Your Authorization under the following three circumstances: (1) when you require emergency treatment; (2) when we are required by law to treat you and we attempt to obtain Your Consent, but are unable to obtain it; and (3) when we attempt to obtain Your Consent but are unable to obtain it due to substantial barriers to communicating with you (e.g., you are unconscious or otherwise incapacitated) and we reasonably infer that you would have consented in the absence of the barriers.

B.Disclosure to Relatives and Close Friends. When you are present in a BRIDGE facility and are capable of communicating, we may use or disclose Protected Health Information to a family member, other relative, a close personal friend, or to any other person identified by you, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure.

If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative, or a close personal friend, we would disclose only information that is directly relevant to the person's involvement with your health care.

C.Fundraising Communications. We may contact you to request a tax deductible contribution to support important activities of THE BRIDGE. In connection with any fundraising, we may disclose to our fundraising staff demographic information about you (e.g., your name, address, and phone number) and dates of health care that we provided to you.

D.Marketing Communications. We may use or disclose Protected Health Information to identify health-related services and products that may be beneficial to your health and then contact you about the services and products.

E.Public Health Activities. We may disclose Protected Health Information for the following public health activities and purposes: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability, as required by law and public health concerns; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk to contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work related illnesses and injuries or workplace medical surveillance.

F.Victims of Abuse, Neglect, or Domestic Violence. We may disclose Protected Health Information without Your Consent or Authorization to a government authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.

G.Health Oversight Activities. We may disclose Protected Health Information to a health oversight agency that oversees the health care system and ensures compliance with the rules of government health programs such as Medicare or Medicaid.

H.Judicial and Administrative Proceedings. We may disclose Protected Health Information in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

I. Law Enforcement Officials. We may disclose Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.

J.Health or Safety. We may disclose Protected Health Information to prevent or lessen a serious and imminent threat to a person's or the public's health or safety.

K.Specialized Government Functions. We may disclose Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State.

L. Decedents. We may disclose Protected Health Information to a coroner or medical examiner as authorized by law.

M.Organ and Tissue Procurement. We may disclose Protected Health Information to organizations that facilitate organ, eye, or tissue procurement, banking, or transplantation.

N.Research. We may use or disclose Protected Health Information without your consent or authorization if our Institutional Review Board or Privacy Board approves a waiver of authorization for disclosure.

1.For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to Protected Health Information, you may contact our Privacy Officer. You may also file written complaints with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with the Director or us.

2.Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of Protected Health Information (1) for treatment, payment, and health care operations, (2) to individuals (such as a family member, other relative, close personal friend, or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction.

3.Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive Protected Health Information by alternative means of communication or at alternative locations.

4.Right to Inspect and Copy Your Health Information. You may request access to your medical record file, as well as your enrollment, payment, claims adjudication, case, medical management records, and your billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you request a copy or copies of your record, you will be charged a cost-based fee for each copy.

5.Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file, enrollment, payment, claims adjudication, case, medical management records, or billing records. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

6.Right to Receive Paper Copy of This Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

Effective Date and Duration of This Notice

1.Effective Date. This Notice describes the privacy policy of THE BRIDGE that will become effective on or before April 14, 2003, the date that federal law specifies for these protections of Protected Health Information. Prior to the effective date, THE BRIDGE will continue to protect your Protected Health Information as required by other applicable laws, regulations, and policies.

2.Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in waiting areas around THE BRIDGE Facilities, and on our Internet site at http://www.bridgeinc.org. You also may obtain any new notice by contacting the Privacy Officer.

Prison Rape Elimination Act (PREA)

WHAT IS PREA

PREA addresses the detection, elimination and prevention of sexual
assault in DYS facilities throughout Alabama.

PREA directs the collection and dissemination of information on the incidence of juvenile on juvenile sexual violence as well as staff sexual misconduct with juveniles in Alabama Department of Youth Services (ADYS) custody, or private providers contracting with ADYS, such as The Bridge.

Does PREA apply to The Bridge?
Yes, PREA applies to all Bridge residential programs contracted with the Alabama Department of Youth Services.

What is the evidence of The Bridge commitment to maintain a safe environment for juveniles?
The Bridge is committed to providing a safe environment for youth. All Bridge staff receive specialized training to ensure that this occurs through initial orientation and subsequent PREA refresher training topics.

When sufficient evidence exists, The Bridge does not hesitate to remove that employee and to support criminal prosecution of that employee.

How does PREA impact Bridge employees?
PREA addresses the safety of juveniles while in a Bridge program - including sexual assault, sexual harassment, juvenile on juvenile sexual assault, and any sexual contact between staff and a juvenile whether or not the contact is alleged to be consensual. PREA pertains to the safety of juveniles or adjudicated offenders while in the custody of the criminal justice system including jail, detention, non-secure residential care, private contracted programs, and/or secure confinement. PREA also directs agencies to maintain data regarding juvenile on juvenile sexual assaults, nonconsensual sexual acts, and staff and juvenile sexual misconduct.

Can The Bridge be sued for not complying with PREA?
No. PREA does not create any right to sue. However, there is an ethical responsibility to protect the safety of staff and those juveniles in custody. Failure to protect incarcerated juveniles can result in civil liability for the agency, supervisors, and staff, both personally and professionally.

What are the consequences for not complying with PREA?
If The Bridge fails to comply with the PREA National Standards for juveniles, The Bridge will be removed as an eligible contract provider for ADYS residential programs.

Why should I be concerned with sexual misconduct at a facility?
Sexual misconduct is not about sex, but about safety and security. Both are compromised whenever boundaries break down and a staff member becomes personal or intimate with a juvenile.

Staff sexual misconduct and juvenile on juvenile sexual assault undermines the mission of The Bridge by creating unstable living and working environments for the juveniles as well as their supervising staff members.

What about juveniles who either manipulate the system using PREA or make false allegations against staff?
Staff are often concerned that addressing PREA-related issues in policy and procedure, and educating juveniles as to their right to be safe while in custody, may result in false accusations or false reports of staff misconduct. All allegations will be thoroughly and timely investigated and false allegations may be prosecuted.

What is The Bridge PREA Policy?
In compliance with Sections 115.311 and 115.322 of the Prison Rape Elimination Act (PREA) Standards, The Bridge has established a zero tolerance for incidents of juvenile sexual assault, rape or sexual harassment in any ADYS facility. The Bridge has implemented policies and procedures to ensure that the PREA Standards are upheld in all Bridge ADYS residential facilities. All allegations of sexual assault/harassment that meet the definitions of PREA are referred for investigations to the local Alabama Department of Human Resources and sheriff offices.

How do I report sexual abuse?
If you suspect sexual abuse has happened at a Bridge facility, you have several options for reporting.

If you prefer, you may call and report to the Sheriff or Police Department in the location where the allegations occurred. All reports are taken seriously and investigated as outlined in PREA and Bridge rules and procedures.

You can report abuse by using a 3rd party form Click Here to download the form.

Additionally, you may call and report to the Alabama Department of Youth Services ADYS PREA Coordinator at 334-215-3802; or you may call the ADYS Sexual Assault Hotline at 1-855-332-1594.

To whom does The Bridge report concerning PREA?
In compliance with PREA Standard §115.389 regarding publication of aggregated sexual abuse data, The Bridge is required to submit reports to the U.S. Department of Justice through the Survey of Sexual Violence Summary form. The Bridge reports that on the 2012 U.S. Department of Justice Survey of Sexual Violence Summary form, The Bridge had no founded allegations of sexual abuse in our ADYS contract residential programs in 2012. The Bridge continues to educate all staff, students, contractors, and volunteers on PREA and the importance of protecting youth from sexual abuse.

“In compliance with PREA Standard §115.389 regarding publication of aggregated sexual abuse data, The Bridge is required to submit reports to the U.S. Department of Justice through the Survey of Sexual Violence Summary form. The Bridge reports that on the 2013 U.S. Department of Justice Survey of Sexual Violence Summary form, The Bridge had no founded allegations of sexual abuse in our ADYS contract residential programs in 2013. The Bridge continues to educate all staff, students, contractors, and volunteers on PREA and the importance of protecting youth from sexual abuse. “

How does the Bridge investigate abuse allegations?POLICY
It is THE BRIDGE policy to ensure that an administrative or criminal investigation is completed for all allegations of sexual abuse, sexual assault, and sexual harassment.

PROCEDURES

When THE BRIDGE conducts its own administrative investigations into allegations of sexual abuse and sexual harassment, it shall do so promptly, thoroughly, and objectively for all allegations, including third-party and anonymous reports.

The Program and QA Managers shall receive special training in sexual abuse investigations involving juvenile victims.

THE BRIDGE shall refer all criminal investigations to the local law enforcement and department of human resource with jurisdiction to conduct such investigations.

Investigators shall gather and preserve direct and circumstantial evidence, including any available physical and DNA evidence and any available electronic monitoring data; shall interview alleged victims, suspected perpetrators, and witnesses; and shall review prior complaints and reports of sexual abuse involving the suspected perpetrator.

THE BRIDGE shall not terminate an investigation solely because the source of the allegation recants the allegation.

The credibility of an alleged victim, suspect, or witness shall be assessed on an individual basis and shall not be determined by the person’s status as juvenile or staff. No facility shall require a juvenile who alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a condition for proceeding with the investigation of such an allegation.

Administrative investigations shall include an effort to determine whether staff action or failures to act contributed to the abuse. All investigations shall be documented in written reports that include a description of the physical and testimonial evidence, the reasoning behind credibility assessments, and investigative facts and findings.

Investigations shall be documented in a written report that contains a thorough description of physical, testimonial, and documentary evidence and attaches copies of all documentary evidence where feasible.

Substantiated allegations of conduct that appears to be criminal shall be referred to law enforcement, department of human resources, and department of youth services for further investigation.

THE BRIDGE shall contact DYS service monitors and/or DYS community residential program administration, and DYS licensing authorities within 24 hours of any alleged sexual abuse incident.

THE BRIDGE shall retain all written reports for as long as the alleged abuser is incarcerated or employed by the agency, plus five years, unless the abuse was committed by a juvenile and applicable law requires a shorter period of retention.

The departure of the alleged abuser or victim from the employment or control of the facility shall not provide a basis for terminating an investigation.

When outside agencies investigate sexual abuse, THE BRIDGE shall cooperate with outside investigators and shall endeavor to remain informed about the progress of the investigation.

At the conclusion of all PREA investigations, the Campus Administrator shall complete THE BRIDGE Investigative Outcomes of Allegations of Sexual Abuse/assault or Sexual Harassment and submit it to THE BRIDGE PREA Coordinator.

THE BRIDGE shall impose no standard higher than a preponderance of the evidence in determining whether allegations of sexual abuse or sexual harassment are substantiated.

The Prison Rape Elimination Act (PREA) on-site audit of the Kennington Addiction Treatment Center in Gadsden, Alabama was conducted March 9-11, 2016 by Georgeanna Mayo Murphy, a U.S. Department of Justice Certified PREA Auditor for juvenile facilties. Pre-audit preparation included a thorough review of all documentation and materials submitted by the facility along with the data included in the completed PRE-Audit Questionnaire. The documentation reviewed included agency policies, procedures, forms, educational materials, training curriculum, organizational charts, posters, brochures and other PREA related materials that were provided to demonstrate compliance with the PREA standards. A review of the materials provided promted several questions that were qucily answered by the PREA Coordinater, Ms Kim Harden. One policy was updated and submitted to the Bridge Inc. management for review prior to the auditors arrival on-site,

During the two and a half day on-site audit, the auditor was provided access to an office in the facility to conduct interviews of administrative and human resources staff. Line Staff and resident interviews were conducted in a lounge in the facility that provided a venue for confidential interviews. Formal interviews were conducted with facility staff, residents and contract personnel. The auditor interviewed ten of the twenty-four residents from the facility. Eight line staff (TA) workers were interviewed along with three counselors/therapist, intake clerk and the program manager. The line staff workers interviewedwere made up of at least two member from each shift both male and female, Specialty staff wer also included in the interview process, the director of training, medical staff, cafeteria staff and maintenance employees. Administrative staff including the Agency Director, Mr. Tim Naugher, Associate Agency Director, Mr. Mark Spurlock, PREA Coordinator, Ms Kim Harden, and PREA Compliance Manager, Ms Angie Pate,
Resident were interviewed using the recommended DOJ protocols that question their knowledge of a variety of PREA protections specifically their knowledge of reporitng mechanisms available to them to report sexual abuse and sexual harassment. Staff were questioned using the DOJ protools tht question their PREA training and overall knowledge of the agency's zero tolerance policy, reporting mechanisms available to residents and staff, the response protcols when a resident alleges abuse, and first responder duties. The auditor reviewed 10 peronnel files of staff members to determine compliance with background check procedures and 10 employee training files to verify compliance with training policies and procedures. All files were found to be in order. Case files for 10 of the clients were reviewed to verify screening and intake procedures, resident education and other general areas mentioned in the standards. In the past 12 months the facility reported one third party report alleging sexual abuse and three reports alleging sexual harassment. The facility provided me with all the investigative information of each allegation and the administrative outcomes. Two staff members were terminated.

The auditor toured the facility escorted by the PREA Coordinator and observed the facility configuration, location of cameras, level of staff supervison, dorm layout including shower and toilet areas, placement of PREA posters and PREA informational resources, security monitoring, resident entrance and exit procedures from the day room to their assigned sleeping area, resident interaction with staff and programming. The auditor noted that there are eight rooms in the facility desined to be sleeping areas. There are three clients placed in each room and they share a common restroom/shower area. Policy allow only one resident be in ther restroom/shower are at any time. Notices of the PREA audit were posted throughout the facility. The auditor was give access to all the parts of the facility to review the DOJ tour protocol. The auditor talked informally with both residents and staff during multiple walk-throughs of the facility during the course of the visit.

The auditor was treated with great hospitality during the on-site visit, Clients and staff were made readily available to the auditor at all
times and were more than willing to participate. Both staff and residents were very knowledgeable abut the protections and requirements of PREA. It is clear that the leadership of the facility has worked very hard to meet compliance with the PREA Standards and have worked toward ensuring the sexual safety of the clients in their care.

DESCRIPTION OF FACILITY CHARACTERISTICS

The Kennington Addiction Treatment Center operates through the Bridge Incorporated which is a not for profit agency. The Bridge was established in 1974 to assist addicted individuals and combat the growing drug problem in northeast Alabama. In the mid 1990's the Bridge began working with the Alabama Department of Youth Services to provide adolescent substance use treatment. The Bridge is licensed by the Alabama Department of Youth Services. Three programs are housed on the grounds of the Bridge Inc. in Gadsden, Kennington is a 24 bed male facility that houses clients betweent the ages of 12-19 with drug abuse issues. There are eight rooms in the facility desined to be sleeping areas. There are three clients placed in each room and they share a common restroom/shower area, Clients share two large day rooms with a staff office in the middle. A camera monitoring system is located in the staff office which faces the clients bedrooms. Clients enjoy a large outdoor recreation area and indoor gym which is a stand alone building. The facility has eight over flow beds in a separate building but these beds have not been in use. The facility has a laundry room but residents are not allowed entrance into that area.
The Kennington facility also houses counselors/therapists for the clients in the program. Each client is assigned a therapist upon arrival to the facility. Clients can request to speak with their therapist at any time to discuss any issues the may behaving. The intake clerk is also located in the facility, She provides each resident with a PREA PowerPoint introduction upon admission to the facility. Residents are only searched by male staff except in exigent circumstances and these searches are always within view of the camera.
Clients attend class in portable buildings and escorted by facility staff from one point to another, Clients also have access to medical care while at the facility. A cafeteria is provided on the campus where clients eat their meals and receive snacks. Administrative offices are located in a building at the entrance of the campus. The average daily population of the facility is 24. There were 140 admits in the last 12 months.

SUMMARY OF AUDIT FINDINGS

During the past 12 months the Kenning Treatment facility reported one allegation of sexual abuse and three allegations of sexual harassment. The sexual abuse allegation is currently being investigated by the Etowah County Sheriff's Department and the Alabama Department of Human Resources, Administraive investigations led to the termination of one staff member.

Overall, the interviews of clients reflected a clear understand of the PREA protections and the agency's zero tolerance policy for sexual abuse and sexual harassment. Clients were very well versed on the options they have to report any sexual abuse or sexual harassment. Clients receive PREA training during the intake process by the intake clerk. She provides them with an individualized explaination of PREA and how it affects them during their stay at the facility. Clients are provided a more in-depth explanation of PREA during the orientation process. Clients are provided with a facility handbook of rules, a “Bridge-Safe” brochure, and “How to Report” business card. Posters are located throughout the facility with the PREA Hotline phone number prominently displayed. Clients were able to articulate to the auditor what they would do and who they would tell if they were sexually abused or harassed at the facility as well as what they would do if they knew another client was being harassed or abused. Clients consistently indicated they felt safe in the facility and did not fear retaliation if they did make an allegation,
All facility staff interviewed indicated they received detailed PREA training and could articulate the meaning of the zero tolerance policy. Staff were knowledgeable concerning their roles and responsibilities in preventing, reporting, and responding to sexual abuse and sexual harassment. Staff were well versed in the variety of reporting mechanisms for both themselves and residents. Staff were well trained on the duties of a first responder and showed the auditor the back of their ID badge which listed those duties. Different scenarios were given and each staff member walked the auditor through the first responder process. No staff member indicated they felt retaliation would be an issue if they made a report or participated in an investigation involving sexual abuse or sexual harassment of a client. The staff training director provided the auditor with the curriculum and forms used to train staff.

Clients are screened during the intake process for vlunerability to ensure safe housing and programming, Couselors/Therapists meet weekly to ensure clients are following the program and aid in maintaining a safe environment. Clients may be re-evlauated periodically for vulnerability if issues arise.

The facility has an MOU with the Etowah County Sheriff's Department to conduct all criminal investigations involving the sexual abuse of a client. They have an MOU with the Children's Hospital of Alabma to provide SANE and SAFE medical staff when doing the sexual assault exam on a client from the facility. They have an MOU with 2nd Chance to provide support services to sexual abuse victims and act as an adovate for the client.

It is clear that the leadership of the facility has worked very hard to meet compliance with the PREA Standards and has worked toward ensuring the sexual safety of the clients in their care

Number of standards exceeded: 4
Number of standards met 34
Number of standards not met: 0
Number of standards not applicable: 3

Standard 115.311 Zero tolerance of sexual abuse and sexual harassment; PREA Coordinator
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The Kennington Treament Center has implemented a zero tolerance policy as detailed in Policy TBI-P-311 which comprehensively addresses the facility's approach to preventing, detecting, and responding to all forms of sexual abuse and sexual harassment. The policy contains the necessary definitions, sanctions and the foundation for training with residents, staff, volunteers, contract personnel and others.

The facility has a designated PREA Coordinator, Ms Kim Harden, her official title is Quality Assurance Manager. The PREA Coordinator reports directly the Executive Director, Tim Naugher. Ms Harden indicated that she has sufficient time and authority to develop, implement, and oversee effords toward PREA compliance and she has one PREA Compliance Manger who reports to her directly,

The facility has a designated PREA Compliance Manager, Angie Pate, Her official title is Lead Therapist. Ms Pate indicates that she has sufficient time and authority to develop, implement and oversee Kennington Treatment Center's efforts to comply with the PREA standards.

Standard 115.312 Contracting with other entities for the confinement of residents
口Exceeds Standard (substantially exceeds requirement of standard)
口Meets Standard (substantial compliance; complies in all material ways with the standard for the
relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The Kennington Treatment Facility does not contract with external entities to house or confine any of its residents. The Alabama Department of Youth Services (DYS) contracts bed space with the facility for residents sentenced to DYS by the court. The standard is therefore not applicable.

Interview with PREA Coordinator
Interview with Agency Director

Standard 115.313 Supervision and monitoring
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The Kennington Treatment Center has a formalized, written staffing plan that addresses the mandatory eleven elements required in the PREA Sandard. The facility maintains legal ratios per the facility state license from the Alabama Department of Youth Services. Staff ratios are 1:8 during waking hours and 1:12 during sleeping hours. Great care is taken to ensure the staffing minimums are maintained at all times. There were no exigent circumstances during this auditing period that left the facility below its staffing minimum. The staffing plan is revised annually to ensure compliance. The facility conductrs unannounced rounds on each shift to identify and deter sexual abuse and sexual harassment. The staff member conducting the roumds monitors to ensure staff are not alerting other staff members that rounds are being conducted. Rounds are documented on the “Supervisory Monitoring Log” form.
The facility’s is video monitoring system is very extensive and more cameras are installed as new blind spots are identified. While the auditor was there for the on-site vist a technician was on campus installing additional external cameras. Supervisory staff can access the facility camera system when not on campus to monitor activities if needed.

Standard 115.315 Limits to cross-gender viewing and searches
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, Including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.
Kennington is an all male facility with both male and female line staff (TA). All rooms are doorm style with three residents sharing one restroom. Kennington policy prohibits cross-gender strip searches and has no exigent circumstances exceptions If a strip search is authorized it is conducted with a member of the medical staff and a same gender staff member. If a body cavity search is authorized it is conducted by a member of the medical staff only. The facility also prohibits any cross-gender pat-down searches except under exigent circumstances. Any time a pat-down search is authorized staff will complete form 115.315 “Same and Cross-Gender Pat-Down Searches”.

All pat-down searches are done so that the staff member and client are in view of the camera. None of the residents interviewed had ever been patted-down by a female staff member.

Facility policy prohibits staff from searching or physically examining a transgender or intersex resident for the sole purpose of determining the resident's genital status.

Kennington policy and practice ensures that residents are able to shower, perform bodily functions and change clothing in privacy. Policy and procedure require announcement when staff of the opposite gender enters the housing unit. Female staff do not enter any room occumpied by a male client or any toilet/restroom area. Interviews with staff and clients confirmed this as the policy and actual practice of the program on a consistent basis.

The facility has provided training for staff on the proper procedure for conducting a pat-down search on a client of the opposite gender or a transgender or intersex resident in a professional manner.

Standard 115.316 Residents with disabilities and residents who are limited English proficient

X Exceeds Standard (substantially exceeds requirement of standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action) Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington policy requires that clients with special needs have an equal opportunity to participate in or benefit from all aspects of the facility’s efforts to prevent, detect and respond to sexual abuse and harassment. Policy further prohibits the use of clients as interpreters when dealing with first responder situations or any allegation/investigation of sexual abuse or harassment. The facility has a contract with Optimal Phone Interpreters who provide foreign language interpreters as well sign language interpreters. PREA information is also provided in a format that can be easily understood for residents with intellectual disabilities, or low reading skills. Residents are given a hearing loss questionnaire as part of the medical screening by their counselor.

口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington policy and procedure prohibits the hiring, enlisting of any contractor or volunteer or promotion of employee, who has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse; or has been civily or administratively adjudicated to have engaged in such activity. Kennington shall consider any incidents of sexual harassment, as defined by PREA, in determining whether to hire or promote anyone, or to enlist the services of any contractor/volunteer, who may have contact with clients. Before hiring new employees, promotions or contracting with any contractor or volunteer Kennington performs a nation-wide criminal background record check, Child Abuse and Neglect Report from the Alabama Department of Human Resources and contacts prior institutional employers for information on substantiated allegations of sexual abuse as well as any resignations which occurred during a pending investigation of an allegation of sexual abuse. The facility also requires all applicants and employees to disclose any previous misconduct in written applications or interviews for hiring or promotions and in any interviews or written self-evaluations conducted as part of the annual performance appraisals of current employees using the Bridge Form “PREA Employment/Appraisal Questionnaire”. Background checks for employees are conducted every five years.

Any material omissions regarding misconduct or the provision of materially false information, shall be considered grounds for termination.

Standard 115.318 Upgrades to facilities and technologies
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington reports that there have been no substantial expansions, modifications or retrofitting of the facility. The facility has installed external and internal cameras to eliminate blind spots. Cameras are strategically placed on all external entrances/exits, common areas, hallways, classrooms, etc, Cameras are monitored by line-staff (TA) in the staff office. Cameras can alos be monitored by administrative staff afterhours if needed.

The agency leadership considers a variety of factors when upgrading technology in the facility including primarily sight lines, blind spots, and inaccessible areas. Interviews with facility leadership indicate tht placement of cameras are discussed frequently to enhance safety for all clients.

Standard 115.321 Evidence protocol and forensic medical examinations
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington refers all allegations regarding sexual assault to the Etowah County Sheriff's Office for criminal investigation purposes. The Sheriff's Department reports using the recommended uniform evidence protocol cited in the PREA Standard. Clients are taken to Children's Hospital of Alabama for all forensic examinations which are conducted by SANE/SAFE medical personnel at no cost to the victim. The facility has an agreement with both the Etowah County Sheriff's Department and Children’s Hosptial of Alabama. The facility provides victims with an advocate through a MOU with the 2"Chance Program. The facility also has a trained support staff member, Ms Conteria Williams.

Kennington conducts and internal investigation of employee misconduct in conjunction with law enforcement. The Campus Administrator, Program Manager PREA Manager and Compliance Director are responsible for conducting and administration of all allegations of sexual assault and/or sexual harassment.

Standard 115.322 Policies to ensure referrals of allegations for Investigations
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies In all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be Included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington policy requires that all allegations of sexual abuse and sexual harassment be referred for investigation to appropriate law enforcement authorities. The Etowah County Sheriff's Department is the law enforcement agency that conducts all criminal investigations at the facility. The policy is posted on the facility's website. The facility also notifies the Alabama Department of Human Resources (DHR) to make a report. Both agencies conduct their own investigations based on the information provided by Kennington. The facility conducts an internal investigation of employee misconduct in conjunction with the law enforcement criminal investigation and the investigation by DHR. The Campus Administrator, Program Manager PREA Manager and Compliance Director are responsible for conducting and administration of all allegations of sexual abuse and/or sexual harassment.

The facility reports one allegation of sexual abuse in the past 12 months and three allegations of sexual harassment. The sexual abuse report was made by a third party (fellow client). The employee involved in the allegation of sexual abuse was terminated and is currently under investigation by the Etowah County Sheriff's Department and Alabama Deparment of Human Resources. The sexual harassment allegations were found to be unsubstantiated. The facility provided the auditor with all the information and findings regarding the sexual harassment complaints and the information regarding the sexual assault complaint.

X Exceeds Standard (substantially exceeds requirement of standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by Information on specific corrective actions taken by the facility.

Kennington policy equires all new employees to have in-depth training on the Prison Rape Elimination Act. PREA training is conducted every two years for all employees as a refresher. Training staff ensure staff are retaining the information presented to them through the use of a post-test and signature verifying receipt. A review of the training materials and discussion with the training director show that staff receive training on all eleven specific topics found in the standard. The training is tailorerd to working with the unique needs of an all male population. During staff interviews it was evident that staff were well versed on the reporting options for themselves and clients, Red Flags, signs and symptoms of abuse and the importance of the duties of a first responder. All staff at the facility have been trained in PREA.

Standard 115.332 Volunteer and contractor training
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington requires all volunteers and contract personnel who may have contact with residents to be trained on the PREA requiremens. The training materials cover all required topics. All volunteers and contract personnel have received training in PREA and signed a form verifying receipt. Training is based on the amount of contact volunteers and contract personnel have with clients.

After interviewing contracted personnel (medical staff and teachers) it was evident they received and understood the information provided to them during PREA training.

Standard 115.333 Resident education
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be Included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington reports that 140 clients were admitted to the facility in the past 12 months and all have been provided comprehensive age-appropriate
information during the intake process. The intake clerk goes over a PREA PowerPoint flip chart with each client individually. Clients receive PREA orientation within 24 hours of arrival. This is monitored by the PREA Compliance Manager to ensure all clients recive training. The PREA Manager also monitors the training of any resident with learning, language or disability barriers. Clients are provided orientation materials during intake, “Bridge-Safe Brochure", and “Your Safety is our Primary Concern” business card. The initial training and orientation training include zero tolerance policy, key definitions of certain conduct, how you can protect yourself, and how to report sexual abuse or harassment. Clients transferred from another agency are educated regarding their rights under PREA. PREA education is available to clients in many different formats for residents who are not English proficient, deaf, visually impaired, who have
limited reading skills.

Key information about PREA is continuously and readily available and visible to residents. Kennington displays PREA posters in common areas of the facility with the abuse hot-line number in bold print. The facility provides translation services through Optimal Language Services.
After interviews with the clients it was evident they received the proper training and were very knowledgeable about the zero tolerance policy, ways to be safe, and how to report.

Standard 115.334 Specialized training: Investigations
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington refers all allegations of sexual abuse to the Etowah County Sheriff's Department for criminal investigations. Kennington conducts an internal investigation of employee misconduct in conjunction with law enforcement. The Campus Administrator, Program Manager PREA Manager and Compliance Director are responsible for conducting and administration of all allegations of sexual assault and/or sexual harassment. The PREA Coordinator, Kim Harden and three other employee have received training in conducting investigations.

Standard 115.335 Specialized training: Medical and mental health care
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions, This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington Treatment Program has nurses (RN's and LPN's) on staff to provide on-site medical care at the facility. A physican comes to the facility to provide medical care on a regulare basis including dental care, x-rays etc. Each client is assigned a counselor/therapist for the duration of their treatment. All medical and mental health staff are trained on the PREA information and sign an acknowledgement statement. Facility staff do not conduct forensic medical exams of clients who are victims of sexual abuse in the facility. Kennington contracts with Children’s Hospital of Alabama to to perfrom sexual assault kits by SANE and SAFE trained medical staff. The 2nd Chance program provides advocates for victims of sexual abuse.

After conducting interviews with medical staff and staff counselors/therapists it was evident that staff were vey knowledgeable about PREA related topics such as mandatory reporting, zero tolerance, rights of residents, etc.

X Exceeds Standard (substantially exceeds requirement of standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

It is the policy of the Kennington Treatment Center that counselors/therapists conduct the Intake Screening for Assaultive Behavior, Sexually Aggressive Behavior and Risk for Sexual Victimization Instrument during their admission process. Clients are also assessed by the medical staff and contract medical providers. Information from these assessments along with other data are used by the Program Manager to make room assignments and determine housing needs. This assessment occurs within 24 hours of the resident arriving at the facility. The facility reports that 140 clients were admitted to the facility in the past 12 months and all were screened as required by this standard.

The Screening Instrument covers all eleven topics as detailed in the standard. Additonal information received during the admission process is added in decisions regarding housing and programming needs.

The facility has implemented appropriate controls on the dissemination of the information received during the admission process. The information received by counselors during the admission process is kept locked in file drawers in their offices. A reasssment of the client is conducted by the counselor periodically to determine if their risk level has changed.

Standard 115.342 Use of screening Information
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

It is the policy of the Kennington Treatment Center that counselors/therapists conduct the Intake Screening for Assaultive Behavior, Sexually Aggressive Behavior and Risk for Sexual Victimization Instrument during their admission process. Clients are also assessed by the medical staff and contract medical providers. Information from these assessments along with other data are used by the Program Manager to make room assignments and determine housing needs. This assessment occurs within 24 hours of the resident arriving at the facility. The facility reports that 140 clients were admitted to the facility in the past 12 months and all were screened as required by this standard.
The Screening Instrument covers all eleven topics as detailed in the standard. Additonal information received during the admission process is added in decisions regarding housing and programming needs.

The facility has implemented appropriate controls on the dissemination of the information received during the admission process. The information received by counselors during the admission process is kept locked in file drawers in their offices. A reasssment of the client is conducted by the counselor periodicallyto determine if their risk level has changed.
The facility does not use isolation so there have been no clients placed on isolation in the last 12 months. Residents who are at risk of sexual victimization will be moved to another program located on the campus (Mitchell). There is no special housing or bed assignement clients who identify as gay, bisexual, transgender or intersex. Housing arrangements for transgender or intersex clients are made on a case by case basis.

Standard 115.351 Resident reporting
X Exceeds Standard (substantially exceeds requirement of Standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, Including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The Kennington Treatment Center provides clients with multiple internal and external ways to report sexual abuse, sexual harassment and retaliation. Clients receive education about reporting at the time of intake by the intake clerk and a comprehensive orientation with 24 hours of their arrival. Clients receive written information such as the Bridge Safe Brochure and a business card with a list of reporting options, Reporting methods include telling a staff member/volunteer/contract employee, written grievane procedure, calling the abuse hotline, having an third party submit an oral or written complaint on the client’s behalf and speaking to the DYS adovocate or their probation officer. Clients are provided access to the tools necessary to make a written report. Clients have access to phone calls with their parent, legal guardian, attorney and probation officer weekly. Clients also are allowed vists from their parent or legal guardian while in the program, Kennington policy allows unimpeded and free access to a phone in a private setting to call the Alabama PREA Hotline which is operated by the Alabama Department of Youth Services.

Interviews with clients clearly demonstrated that all were very knowledgeable about PREA and the variety of methods to report sexual abuse and sexual harassment. Clients know how to call the hotline, and file grievances. Clients told the auditor they could make a call to the PREA Hotline at any time. Clients also informed the auditor that they would not fear any intimidation or retaliaton if they reported sexual abuse or sexual harassment. Clients stated they felt safe in the facility. Interviews with line staff and counselors/therapists also demonstrated they were aware of the residents reporting options.

Standard 115.352 Exhaustion of administrative remedies
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be Included in the Final Report, accompanied by Information on specific corrective actions taken by the facility.

The Kennington Treatment Center has a formalized written grievance system for clients. Clients may submit a grievance regarding an allegation of sexual abuse or sexual harassment at any time. Clients may receive assistance in preparing and filing a grievance. Grievance boxes are located in the common areas and forms and writing utensils are made readily available to clients. Facility policy and procedure require that a decision on the merits of any grievance or portion of a grievance alleging sexual abuse be made within 90 of filing the grievance. In the past 12 months two grievance were filed alleging sexual abuse or sexual harassment. A final deciosn regarding both grievances was reached within the proper time frame.

The client handbook informs residents of the grievance process as well as training received during the orientation process. There is no time limit in which a resident may file a grievance concerning sexual abuse or sexual harassment. Clients do not have to attempt to resolve these type of disputes with staff or other clients before filing a grievance.

The facility policy provides emergency grievance procdurs however in the past 12 months no emergency grievances have been filed.
Interviews with clients and staff demonstrated a thorough understanding of the grievance process and procedures.

Clients also have an outside grievance option through the DYS Adovocate who vists the facility weekly and checks the DYS grievance box.

Standard 115.353 Resident access to outside confidential support services
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by Information on specific corrective actions taken by the facility.

The Kennington Treatment Center has reported one allegation of sexual abuse in the past 12 months however the resident who made the report was released prior to the audiors arrival at the facility for the on-site visit. The allegation was made by a third party (another client) and is currently under investigation by the Etowah County Sheriff’s Department and Alabama Department of Human Resources. An internal investigation led to the termination of the employee.
Support services are offered through a contract with the 2nd Chance Program which provides an outside victim adovocate for emotional support services related to sexual abuse. Clients may also call the Rape Crisis Centers National Hotline which provides confidential support services. The facility also provides clients with reasonable access to their parents/legal guardians, attorneys, probation officers, DYS advocate and monitors through phone calls, visits and letters.

Standard 115.354 Third-party reporting
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The Kennington Treatment Center has reported one allegation of sexual abuse in the past 12 months however the resident who made the report was released prior to the audiors arrival at the facility for the on-site visit. The allegation was made by a third party (another client) and is currently under investigation by the Etowah County Sheriff's Department and Alabama Department of Human Resources. An internal investigation led to the termination of the employee.

The facility provides clients with reasonable access to their parents/legal guardians, attorneys, probation officers, DYS advocate and monitors through phone calls, visits and letters. The third party reporting procedures are located on line on the facility website and are found in the pareny handbook.

Standard 115.361 Staff and agency reporting duties
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon In making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

It is the policy of the Kennington Treatment Center that staff are required to immediately report any knowledge, suspicion or information regarding an incident of sexual abuse or sexual harassment that occurred in a program, whether or not it is part of The Bridge; knowledge of any retaliation against clients or staff who reported such an incident and any staff neglect or violation of responsibilities that may have contributed to an incident or retaliation. All staff are required to comply with their duties as a mandatrory child abuse reporter. Apart from reporting to the Program Manger, PREA Coordianator/Manager or investigative agencies staff are prohibited from revealing any information related to a sexual abuse report to anyone other than to the extent necessary to make treatment, investigations, and other security management decisions.

Standard 115.362 Agency protection duties
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, Including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The facility reports that there have been no situations in the past 12 months where the facility determined a client was subject to substantial risk of sexual abuse, Review of policy and interviews with PREA Coordinator and Program Manager demonstrated the protective measures that would take place in the event it was found that a client was in imminent danger of being sexual abused.
Policy TBI-P-311
Policy TBI-P-362
Interviews with Line Staff
Interviews with Counselors
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Training information

Standard 115.363 Reporting to other confinement facilities
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.
.
The facility reports that in the past 12 months, the facility has received no allegations that a client was abused while confined in another facility. The policy clearly requires the Agency Director to report any abuse allegations received regarding a client abused at another facility to the head of the facility where the sexual abuse is alleged to have occurred. Policy requires this notification occur as soon as possible but no later than 72 hours of receiving the allegation.

Standard 115.364 Staff first responder duties
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The Kennington Treatment Center has reported one allegation of sexual abuse in the past 12 months however the resident who made the report was released prior to the audiors arrival at the facility for the on-site visit. The allegation was made by a third party (another client) and is currently under investigation by the Etowah County Sheriff's Department and Alabama Department of Human Resources. An internal investigation led to the termination of the employee,
The facility has a policy regarding the duties of first responders whether they be “security staff" or “non-security staff". The facility provides all staff with ID cards which have first responder duties listed on the back. Frist responder protocol forms detail what steps to take in the event the abuse took place within 72 hours or after 72 hours. Security staff who are first responders will separate the alleged victim and abuser, secure the crime scene, request that neither the victim or abuser destroy evidence (as detailed in the standard). If the staff is considered a "non-security staff" their duties are to notify security staff and request the allege victim not take any actions that may destroy evidence. Interviews with both security and non-secuirty staff showed they were very knowledgeable of their duties and how to carry them out.

Standard 115.365 Coordinated response
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, Including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by Information on specific corrective actions taken by the facility,

The facility has a written institutional plan to coordinate actions taken in response to an incident of sexual abuse among staff, first responders, medical and mental health practitioners, investigators and facility leadership.

Standard 115.366 Preservation of ability to protect residents from contact with abusers
口 Exceeds Standard (substantially exceeds requirement of standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

This standard is not applicable to the Kennington Treatment Center. Staff employeed by the facility are at will employees and can be terminated at any time. The facility does not participate in collective bargaining agreements.

Standard 115.367 Agency protection against retaliation
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The facility reports there have been no incidents of retaliation in the past 12 months. The Kennington Treatment Center has a policy to protect all juveniles and staff who report sexual abuse or sexual harassment or cooperate with sexual abuse or sexual harassment investigations from retaliation by other clients or staff. The Campus Administrator and PREA Manager are responsible for monitoring retaliation of staff and clients. The Campus Administrator and PREA Manager monitor the conduct or treatment of staff or clients who reported sexual abuse and clients who reported having sufferd abuse to see if there are any changes that may suggest possible retaliaton by clients or staff. This monitoring period last for no less than 90 days. The facility employes multiple protection measures, such as houing changes or transfers for juvenile victims or abusers, removal of alleged staff or juvenile abusers from contact with victims and emotional support services for clients or staff that fear retaliation for reporting sexual abuse or sexual harassment or for cooperating with investigations. It is the policy of the facility to act promptly to remedy any such situation. Inteviews with staff and clients confirmed that they did not fear retaliation and knew that it would be monitored if a report was made.

Policy TBI-P-311
Policy TBI-P-367
Form 115.367
Form 115.371
Interview with PREA Coordinator
Interview with PREA Compliance Manager
Interview with Program Manager
Interview with Campus Administrator
Interviews with line staff
Interviews with clients
Interviews with Teachers
Interviews with Medical Staff

Standard 115.368 Post-allegation protective custody
口 Exceeds Standard (substantially exceeds requirement of standard)
口 Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The Kennington Treatment Center reports they do no use isolation in their facility. There a no isolation rooms or single cells in the facility. The facility has rooms that house three clients. If a client rose to a level where his safety was in question he would be moved to another facility on campus (Mitchell) or restaffed by DYS, The standard is not applicable to the facility.

Standard 115.371 Criminal and administrative agency investigations
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Criminal investigations are conducted by the Etowah County Sheriff’s Department and Administraive Investigations are conducted by trained staff members. Investigations are not terminated soley because the source of the allegation recants. The facility reports one substantiated allegation that was referred for criminal investigation. This allegation is currently being investigated by the Etowah County Sheriff's Department and Alabama Department of Human Resources. The administrative investigation led to the termination of the staff member involved. All written reports pertaining to administrative investations and criminal investigations are retained for as long as the alleged abuser is held at the facility or employed by the facility plus five years.

Standard 115.372 Evidentiary standard for administrative investigations
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, Including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The Kennington Treatment Center reports that they use a standard of proof no higher than that of a preponderance of the evidence in determining whether allegations of sexual abuse or sexual harassment are substantiated. Interviews with investigative staff cofirm compliance with this standard.

Standard 115.373 Reporting to residents
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by Information on specific corrective actions taken by the facility.

The Kennington Treatment Center has reported one allegation of sexual abuse in the past 12 months however the resident who made the report was released prior to the audiors arrival at the facility for the on-site visit. The allegation was made by a third party (another client) and is currently under investigation by the Etowah County Sheriff’s Department and Alabama Department of Human Resources. An internal investigation led to the termination of the employee.

There were also three allegations of sexual harassment by residents at the facility. Residents were notified of the outcome of the administrative investigation on all these allegations. The resident in the sexual abuse allegation was notified of the administrative investigation outcome but has not received information related to the criminal investigation outcome at this time.

The policy of the facility follows the criteria set forth in the standard. Interviews with residents and administrative staff along with the completed notification paperwork show that the facility is following policy procedure and practice.

Standard 115.376 Disciplinary sanctions for staff
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by Information on specific corrective actions taken by the facility.

It is the policy of the Kennington Treatment Center that staff will be subject to disciplinary sanctioins up to and including termination for violating agency sexual abuse or sexual harassment policies. Termination shall be the presumptive disciplinary sanction for staff who have engaged in sexul abuse, Disciplinary sanctions for violations of agency policies relating to sexual harassment shall be commensurate with the nature and circumstances of the acts committed, the staff member's disciplinary history, and the sanctions imposed for comparable offenses by other staff with similar histories. All terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by staff who would have been terminated if not for their resignation, shall be reported to law enforcement agencies, unless the activity was clearly not criminal, and to any relevant licensing bodies. Kennington shall retain investigative documentation and disciplinary information related to any case of sexual abuse, harassment, or misconduct in the employee file and/or juvenile file until seven years past minority status of the alleged juvenile victim. The personnel file shall be marked “Do Not Destroy” with the anticipated date for destruction.
No identifying juvenile information shall be maintained in the personnel file. The employee will not be eligible for re-employment with a Bridge program in any capacity either through internship, volunteer or contractor status. In the past 12 months one employee was terminated for sexual abuse which is now under investigation by the Etowah County Sheriff's Department.

Standard 115.377 Corrective action for contractors and volunteers
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, Including the evidence relied upon In making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility,

Kennington Treament Center reports that there have been zero contractors/volunteers reported to law enforcement or relevant licensing bodies in the past 12 months for engaging in sexual abuse of clients. Interviews with the PREA Coordinator and PREA Compliance Manager indicate that the practice conforms with this standard.

Standard 115.378 Disciplinary sanctions for residents
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; compiles in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The Kennington Treatment Facility reports that in the past 12 months there have been zero administrative findings of resident on resident sexual abuse at the facility; additionally, Kennington reports there have been zero criminal findings of guilt for resident on resident sexual abuse in the past 12 months. The facility prohibits isolation for any purpose therefore there are no reports of resident being placed on isolation as a disciplinary sanction. Kennington policy prohibits all sexual activity between residents. The facility reports that residents who commit PREA realted abuse or harassment would be counseled, moved to another program or referred back to the Alabama Department of Youth Services for restaffing.

It is the policy of the facility that disciplinary action will only be taken against a client for sexual contact with a staff member upon a finding that the staff member did not consent to such contact. A report of sexual abuse made in good faith based upon a reasonable belief that the alleged condcuct occurred shall not constitute falsely reporting an incident or lying even if the investigation does not establish evidence sufficient to substantiate the allegation.

Standard 115.381 Medical and mental health screenings; history of sexual abuse
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

It is the policy of the Kennington Treatment Center that all residents are screened for Assaultive Behavior, Sexually Aggressive Behavior, and Risk of Sexual Victimization upon admission. If the screening indicates that a client has experienced prior sexual victimization no matter where it occurred he is offered a follow-up meeting with the medical staff and a counselor within 14 days. If a client indicates he has been a sexual aggressor he will alos be offered a follow-up medical meeting with the medical staff and a counselor within 14 days. Medical and mental health practitioners obtain informed consent from residents before reporting information about prior sexual victimization or abusiveness.

Standard 115.382 Access to emergency medical and mental health services
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

It is the policy of the Kennington Treatment Center that victims of sexual abuse in the facility receive immediate medical treatment. All forensic medical examinations are conducted by Children's Hospital of Alabama through an agreement with the facility. The 2nd Chance Program provides advocates for victims of sexual abuse. Residents are offered tests for sexually transmitted infections as medically appropriate. Treatment is provided at no cost to the victim. Each client at the facility has an assigned counselor. Staff are trained in the duties of first responders to ensure the client is separated from the alleged abuser, the scene is secured and the proper person is notified (medical supervisor or program manager).

The one sexual abuse allegation which was made was through a third party report. The resident client the proper medical and mental heatlh care once the information was recived by staff.

Standard 115.383 Ongoing medical and mental health care for sexual abuse victims and abusers
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by Information on specific corrective actions taken by the facility.

It is the policy of the Kennington Treatment Center that victims of sexual abuse in the facility are offered medical and mental health evaluations. The treatment includes follow-up services, treatment plans and referrals for continued care following their transfer or placement in another facility. The level of medical care is consistent with that in the community. Kennington is a male treatment facility so pregnancy concerns are not applicable. Residents are offered tests for sexually transmitted infections as medically appropriate. Treatment is provided at no cost to the victim. Kennington will conduct a mental health evaluation of all known resident-on-resident abusers within 60 days of learning of such abuse history and offer treatment when deemed appropriate by mental health practitioners.

All forensic medical examinations are conducted by Children's Hospital of Alabama through an agreement with the facility. The 2nd Chance Program provides advocates for victims of sexual abuse. Each client at the facility has an assigned counselor.

The one sexual abuse allegation which was made was through a third party report. The client received the proper medical and mental heatlh care once the information was recived by staff.

Standard 115.386 Sexual abuse Incident reviews
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

It is the policy of the Kenningron Treatment Center to conduct a sexual abuse incident review at the conclusion of every criminal or administrative sexual abuse investigation, unless the allegation was determined to be unfounded. There is currently one criminal investigation that is ongoing. The employee was terminated after an internal investigation found the claim to be substantiated. A review was completed once the internal investigation was concluded and recommendations were submitted to the agency head. These recommendation were implemented.

Standard 115.387 Data collection
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

The Kennington Treatment Center collects accurate data for every allegation of sexual abuse at the facility using a standardized instrument (The Survey of Sexual Violence used by the DOJ and BJS). This information is collected annually Kennington Treatment Center reviews data collected and aggregated in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies and training. The information is used to identify problem areas, corrective actions, and the prepration of the annual report. The annual report includes a comparision of the current year's data and corrective actions taken in prior years. The annual report is made readily available of the facility's website after approval by the agency director.

Standard 115.388 Data review for corrective action
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington Treatment Center reviews data collected and aggregated in order to assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies and training. The information is used to identify problem areas, make corrective actions, and the prepration of the annual report. The annual report includes a comparision of the current year's data and corrective actions taken in prior years. The annual report is made readily available of the facility’s website after approval by the agency director.

Standard 115.389 Data storage, publication, and destruction
口 Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard for the relevant review period)
口 Does Not Meet Standard (requires corrective action)Auditor discussion, including the evidence relied upon in making the compliance or non-compliance determination, the auditor's analysis and reasoning, and the auditor's conclusions. This discussion must also include corrective action recommendations where the facility does not meet standard. These recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken by the facility.

Kennington Treatment Center policy and procedure and practive ensure the incident based and aggregate data are securely retained. The aggregated data is made readily available to the public on the facilitiy's website. All personal identifiers are removed before the information is made public. Sexual abuse data is retained for at least 10 years after the date of the initial collection.

AUDITOR CERTIFICATION I certify that:
X The contents of this report are accurate to the best of my knowledge,
X No conflict of Interest exists with respect to my ability to conduct an audit of the agency under review, and
X I have not included in the final report any personally Identifiable information (PII) about any inmate or staff member, except where the names of administrative personnel are specifically requested in the report template,